<!DOCTYPE html PUBLIC "-//W3C//DTD XHTML 1.0 Transitional//EN" "http://www.w3.org/TR/xhtml1/DTD/xhtml1-transitional.dtd">
<html xmlns="http://www.w3.org/1999/xhtml">
<head>
<meta http-equiv="Content-Type" content="text/html; charset=UTF-8" />
<meta http-equiv="X-UA-Compatible" content="IE=8" />
<title><!--%nom_fonction%--></title>
<link rel="stylesheet" type="text/css" href="../css/main.css" />
<link rel="stylesheet" type="text/css" href="<!--%css_module%-->" />

<!--link rel="stylesheet" type="text/css" href="../production/contrat/list.css" /-->
<!-- link rel="stylesheet" type="text/css" href="../css/list.css" /-->
<!--link rel="stylesheet" type="text/css" href="../production/modadmin/list.css" /->
			    <!--[if IE 7]>
            	<link rel="stylesheet" type="text/css" href="../css/ie7.css" />
            	<link rel="stylesheet" type="text/css" href="form_ie7.css" />
            <![endif]-->


</head>
<body>
<div id="sf_menu1">
<h3><!--%nom_module%--></h3>
</div>
<div class="corps1">
<div id="information_erreur">
<ul id="message">
	<!--%loop:messages%-->
	<li><!--%message%--></li>
	<!--%endLoop:messages%-->
</ul>
</div>
<div class="cleared"></div>
<div id="br"></div>
<div class="imgleft2"></div>
<div class="imgmiddle2">
<form action="<!--%edit_action%-->" method="post" name="form1" id="form1">
<div class="btn"><span class="btnleft"></span> <span
	class="btnmiddle">
<h5><!--%nom_fonction%--></h5>
</span> <span class="btnright"></span></div>

<div class="formulaire">
<table class="tabform">
	<!--%loop:champ_input%-->
	<!--%if:isset($['label_select_1'])%-->
	<tr>
		<td><!--%label_select_1%--></td>
		<td><select name="
			<!--%select_name_1%-->
			">
			<!--%loop:options_1%-->
			<option value="<!--%option_value_1%-->"><!--%option_name_1%--></option>
			<!--%endLoop:options_1%-->
		</select></td>
	</tr>
	<!--%endIf%-->
	<!--%if:isset($['label_input'])%-->
	<tr>
		<td><!--%label_input%--></td>
		<td><input type="text" name="<!--%input_name%-->"
		maxlength="<!--%maxlength%-->" class="<!--%class%-->" value="<!--%input_value%-->"
		/></td>
	</tr>
	<!--%endIf%-->
	<!--%endLoop:champ_input%-->
</table>
</form>
</div>
<div class="bt1"><a href="choix_reglement_sinistre.php"> <span
	class="btleft"></span> <span class="btmiddle">Annuler</span> <span
	class="btright"></span> </a></div>

<div class="bt1"><span class="btleft"></span> <input type="submit"
	name="Valider" value="Valider" class="resizeall btmiddle" /> <span
	class="btright"></span></div>

</div>
</body>
</html>
